In the world of childbirth, it is axiomatic that C-sections are “bad,” high C-section rates are “epidemic” and massive efforts should be directed toward lowering the C-section rate.
But what if C-sections are better and safer than vaginal birth? What if — despite initial risks and costs — they prevent serious, life altering, expensive complications in the future.
An editorial in The American Journal of Obstetrics and Gynecology raises that possibility.
Shouldn’t we be offering all pregnant women a choice of elective C-section?
As Dr. Catherine Bradley explains:
Pelvic organ prolapse (POP) is a benign gynecological condition that has an impact on many women. An estimated 13% (1 in 8) of US adult women will undergo surgery for POP by the age of 80 years, suggesting a great many more women will experience POP symptoms but may seek nonsurgical care or no intervention. Milder POP (prolapse that remains inside the hymen with straining) is usually asymptomatic, but moderate to severe POP is associated with significant and negative effects on women’s daily life activities, including bothersome vaginal bulge or protrusion symptoms, obstructive urinary and defecatory symptoms, sexual dysfunction, and impaired quality of life with effects on mood, sleep, relationships, and social activities.
Although the causes are multifactorial, vaginal birth is the biggest risk factor.
…[I]ncreasing evidence suggests vaginal birth is the most important risk factor for POP, particularly in those presenting at younger ages. Researchers have identified postdelivery levator ani injuries, identified as levator tears and ballooning, as key factors connecting vaginal birth and the development of POP.
A 2011 paper by Handa et al. makes this clear.
Compared with cesarean without labor, spontaneous vaginal birth was associated with a significantly greater odds of stress incontinence (odds ratio [OR] 2.9, 95% confidence interval [CI] 1.5–5.5) and prolapse to or beyond the hymen (OR 5.6, 95% CI 2.2–14.7). Operative vaginal birth significantly increased the odds for all pelvic floor disorders, especially prolapse (OR 7.5, 95% CI 2.7–20.9). These results suggest that 6.8 additional operative births or 8.9 spontaneous vaginal births, relative to cesarean births, would lead to one additional case of prolapse…
In other words, 1 in every 9 women who have a vaginal birth instead of a C-section will go on to develop pelvic organ prolapse. The number is even higher for operative (forceps or vacuum) vaginal birth. One in 7 women who undergo operative vaginal delivery instead of C-section will develop POP.
The consequences are not trivial and a great deal of vaginal surgery including hysterectomy is done to correct it. That doesn’t count the expense of incontinence pads and the impact on women’s quality of life and sexual function.
We’ve known for a long time that C-sections are safer for babies. It has been nearly 10 years since I first wrote about article Neonatal Morbidity and Mortality After Elective Cesarean Delivery by Signore and Klebanoff appeared in the June 2006 special issue of Clinics in Perinatology focussing on the epidemiology and neonatal effects of C-section.
The authors conducted a decision analysis:
modeling the probability of perinatal death among a hypothetical cohort of 2,000,000 women who had uncomplicated pregnancies at 39 weeks, half of whom underwent ECD and half managed expectantly. After taking multiple chance probabilities into account, the model estimated that although neonatal deaths were increased among women delivered by elective cesarean, overall perinatal mortality was increased among women managed expectantly, because of the ongoing risk for fetal death in pregnancies that continue beyond 39 weeks.
They found that C-sections were dramatically safer for babies:
In other words, if 1 million women underwent C-section at 39 weeks instead of waiting for onset of labor and attempting vaginal delivery, 692 more babies would be saved, 517 cases of intracranial hemorrhage and 377 brachial plexus injuries would be prevented. In exchange, there would be 8476 additional cases of short term respiratory problems, 5536 neonatal lacerations, and 2212 additional cases of postpartum hemorrhage.
Given the short and longterm benefits of C-sections to both babies and mothers, shouldn’t we reconsider our knee-jerk rejection of maternal request C-sections? Shouldn’t we be offering all pregnant women a choice of elective C-section?
Imagine if men experienced lacerations, incontinence and sexual dysfunction in order to have children. Do you think anyone would be wailing about a C-section “epidemic” then? Or would C-sections become as popular as Viagra?
Dear Dr Amy, I’m from Australia and a huge fan. This article was published today in the Sydney Morning Herald – our major Sydney metropolitan newspaper. Would love to hear your take on it. I found it frightening that authorities may take this study as a way to discourage caesarians. https://www.smh.com.au/healthcare/childbirth-program-reduces-caesarean-rate-could-save-health-system-97-million-a-year-20180319-p4z53k.html
Perhaps this is in the running for the rhetorically question of the year award.
Those of you who had a cesarean section by request, any advice on how to find the right doctor and what to say?
Ask. I happily do MRCS. I’m in a group of 4, 3 do them. The 4th will not. Pts in our county know & drift towards the doc who is like them (rural, only hospital & we are only group there). We also do VBACs with the caveat that when we run the risk calculator & you pop out as under 60% success rate, we strongly counsel you to do a repeat CS.
I’m older & trying to reduce my OB load. I do a ton of pessaries – you would be surprised at how many 40-somethings have 1.
A pessary is the thingy that prevents the uterus from falling out of the vagina?
I would be surprised, but you can buy disposable pessary-ish things at the grocery store now. I figure it must be a pretty common occurrence.
Where are you located? In Canada it’s up to the individual doctor. I’ve heard of women here being told they’re “not allowed” to request c section, but that is untrue. My doctor tried half-heartedly to convince me against it but I told him my reasons (risk of prolapse, tearing, stillbirth, etc) and I think he realized I had weighed the pros and cons. If he would have said no, I would have found another OB.
Quincy, Massachusetts. It’s about a half-hour from Boston. I’ve tried three doctors so far. I’ll keep trying though.
I do support maternal request C-section. I had one myself. I do see, however, why it could make OBs nervous. The issue reminds me of tubal ligation. Women rightly complain when their doctors decline to do sterilization. For example in my state, women on Medicaid have a mandatory waiting period…in the meantime they sometimes fall pregnant, and they are (rightly) angry. Shouldn’t it be their right, and nobody else’s to decide? Isn’t it a simple question of bodily autonomy? And yet, as a doctor, I frequently meet women who end up wanting another baby after all. Life happens: divorce, remarriage, sometimes even the death of a child. The rich women can afford the IVF. The poor women never can.
How often would something similar happen with women and CS? Maternal request CS can be a great idea for women who plan no more pregnancies. And it’s not a bad idea for women who plan only one more additional pregnancy. But for women who want 3 or more kids? It starts to be more and more risky. Disorders of placental adherence can be fatal. So what would this mean for policy? Would we deny some women MRCS because we doubted that they would really stop at 2? Would there be a formula based on a combo of age and parity like there used to be (or sometimes still is) with tubal ligation? Would MRCS be reserved for women like myself: rich, educated, older, “respectable”, “stable”?
They already are reserved for such women. Who else can doctor-shop and convincingly advocate for herself? Doctors, like everyone else, are more likely to give the benefit of the doubt to people who look and sound like themselves. So lawyers and architects will get a peaceful MRCS, while the terrified immigrant with no English and little education has to suffer through an unwanted vaginal delivery.
The best way to reduce discrimination is to eliminate discretion. A rule that any woman who wants a MRCS can have one puts the decision back where it belongs: with the person it affects most.
“A rule that any woman who wants a MRCS can have one puts the decision back where it belongs: with the person it affects most”
That rule of thumb sounds wonderful, but how will it work in the real world? Right now, in the real world, if an OB tells a woman she needs a CS, she has the right to refuse, BUT also has the right to later sue the OB if there is a bad outcome claiming she “couldn’t really understand the risk.” And these women win. Something similar would happen with MRCS. And that’s just looking at it from a medical-legal standpoint, then there’s the human standpoint. Disorders of placental adherence WILL go up. Some women WILL bleed to death on the operating table as the OBs (and nurses and surg techs and anesthesiologists) try to save them. This sort of case is devastating and traumatizing for everyone involved.
Then the patient should be told the risks of BOTH types of deliveries and decide for herself. Childbirth seems to be one of the few areas of medicine where there are two almost equal options, but the patient is only allowed to have one of them.
If your concern is lawsuits, then what needs to happen is that more women sue for the damage done by vaginal birth, particularly if they can document that they requested a c-section.
More women suing for vaginal birth damages is a fine thing, but that doesn’t change or help the situation I laid out above, either in a medical-legal sense or in a human tragedy sense.
And I agree that childbirth is an interesting case with 2 acceptable options, but only one that is pushed. But it is not the only area of medicine that is paternalistic. And when I say paternalistic, I don’t automatically mean that in a 100% negative way. It’s not that I like the dynamic, it’s that I don’t see a great alternative. Conflict between what patients wants and what the doctor feels is in their best interest is a huge part of many doctor-patient interactions. Very truthfully, my work as a primary care physician consists largely of convincing people to accept what they have already decided against. Nobody wants to go on a statin or a blood pressure pill, they all want to “try a little longer” with diet and exercise. They want a sleeping pill, not a referral to a cognitive behavioral therapist. They want to do their colonoscopy “next year.” They want those shots never.
It would be sooooo tempting to err on the side of patient autonomy. A quick little Risks and Benefits spiel and then a quick segue to “but I understand that everybody’s priorities are different and so your choice is fine.” My workday would be 50% shorter and easier, and my patients would be thrilled…until they suffered.
Oh my goodness yes! I’m not a family physician, but rather a dietitian who works with them. I receive so many referrals for clients who want to avoid medications, but who aren’t ready, able, and/or willing to make the required lifestyle changes, or, in some cases, all the lifestyle changes in the worldwon’t negate the need for medication. Although there was one client with type 2 Diabetes who was trying to avoid starting insulin. I gave this person the honest truth on what would be required, in terms of diet and exercise, to control their blood sugars sufficiently, with the current medications, to avoid starting insulin. Two days later they called, asking to meet with the diabetes educator for an insulin start.
“But for women who want 3 or more kids? It starts to be more and more risky. Disorders of placental adherence can be fatal. So what would this mean for policy? Would we deny some women MRCS because we doubted that they would really stop at 2? Would there be a formula based on a combo of age and parity like there used to be (or sometimes still is) with tubal ligation? Would MRCS be reserved for women like myself: rich, educated, older, “respectable”, “stable”?”
For a drug-addicted teenager that is being pimped out, states she does not desire further pregnancies, but who is unlikely to prevent further pregnancies?
For an illiterate immigrant who is essentially ‘owned’ by her husband, whose objective is to produce as many male offspring as possible?
Look at the list of privilege in the subsequent post, and decided how many of those factors need to be present in order to award MRCS.
Repeat cesarean section births, grand multiparity, and short interpregnancy intervals risk mothers’ lives. There are often social and medical comorbitidites on top of this.
If everyone meets the criteria on the privilege list – a MRCS is a lovely option.
Who likes the 5th cesarean, or 6th or more?
How does your facility plan for a cesarean delivery after 4 or 5 or 6 prior cesareans? This is never a normal, routine delivery.
What if the patient wants more children? Oh, and she’s homeless.
Maybe I’m being naïve, but I don’t understand the implacable animosity towards sections. It’s a form of preventative medicine-in any other area of healthcare, preventative medicine is considered ethical and appropriate. Every treatment has pros and cons but we seem to be very happy to put the entire population on statins on the grounds of disease prevention, for example. Given the recognised burden of ill health and disability caused by vaginal birth, surely the risk-benefit assessment is in favour of sections, which means its unethical to withhold them.
It can feel like the choice is between this ‘natural’ experience, and surgery (insert scary noises).
What that simplistic view ignores is that natural doesn’t necessarily equal good, or safe, or comfortable. I never heard a word about prolapse, or incontinence or anything else as a result of normal delivery while I was pregnant, which was a long time ago. Perhaps the point was that if there was no way round, the only way was through, so no point worrying about it. That said, if I’d ended up with any of that (so far, so good) I might be cranky about having not had the information.
Usually we have surgery to correct or deal with something undesirable, which the birth usually isn’t. An MRCS doesn’t cure anything; it averts these issues that women have been dealing with forever anyway. Perhaps the lay people pushing it don’t believe these things are really a problem, if they’ve never had it themselves.
You’re right there. We tend to compare the best case vaginal birth scenario against the worst case c-section scenario. This isn’t an accurate representation of the risk profile of vaginal birth. Thus it makes it seem as though choosing a c-section is guaranteeing a negative outcome and choosing a vaginal birth is guaranteeing a perfect experience. (As a side note, I find it odd when people say that they chose or will choose to have a vaginal birth. You can choose to attempt a vaginal birth, but unless you take yourself out into the wilderness or point blank refuse a c-section, you can never guarantee you’ll get a vaginal birth. Thus the decision to have a vaginal birth would be more accurately termed a decision to ATTEMPT vaginal birth.)
Thanks for saying that, as it reminded me about one of my big concerns with birth plans. I love a plan, but know that my capacity to plan accurately is directly related to the control I have over the subject of my plan.
For instance, I can plan a work related project pretty well, with appropriate buy-in and budget.
Birth plan though? As a high level wish, everyone will be alive. Drilling down a little, everyone will be well. Anything beyond that is at best aspirational and at worst an active hindrance to the first two.
Birth plan though? As a high level wish, everyone will be alive. Drilling down a little, everyone will be well. Anything beyond that is at best aspirational and at worst an active hindrance to the first two.
Exactly. I’d honestly never heard of a “birth plan” before I was pregnant, and when the midwife asked if I had one–initially I was with hospital midwives, until it turned out I had mono-di twins–I said, “That sounds like an oxymoron.”
Then I told her my birth plan was everyone remains alive, well, and hopefully untraumatized. That’s it.
The second time around I had a list of reminders for my husband 🙂 Top of the list being DON’T HAND ME THE PHONE RIGHT AFTER I’VE GIVEN BIRTH. My mom got of the phone quickly but his mother did not. I was exhausted and starving.
To be pedantic, you’re not guaranteeing VB even then. You might die before the baby is out.
Too true.
The recent BMJ articles about CS reduction in China made me eager.
Basically, the rate went down because targets and sanctions were imposed- there was no indication that perhaps women might *want* a CS!
RAGEY!!!
Not “eager” 🙂
I had an elective C section though two doctors (an OB and an anesthesiologist) tried to make me change my mind. The OB said that the pregnancy was the cause for POP and incontinence, not birth!! and when I said adhesions/next pregnancy complications were not a concern for me because I was not having another baby asked me how do I know I that..
I recovered relatively easy, I didn’t feel more than 30 seconds of intensive pain. The rest was comparable to muscle soreness after an intensive workout.
This was my CS experience too – it was like I’d done WAAAAYYYY too many sit-ups, but otherwise I felt fine.
Felt *great* in fact – I was so sick while pregnant that just being postpartum felt incredible. No nausea! No rising BP! No constant hip and back pain!
The first couple of days of my recovery were shit, but that’s a whole other rant.
(For all the warnings about c-sections being major abdominal surgery, it still seems to be acceptable to keep a woman waiting two hours for pain relief the day after having one, and then to berate her about “not coping” if she asks if there’s anything that isn’t paracetamol. But maybe any kind of surgery specific to women would get the same dismissive attitude?)
In my experience, when I had my tubal ligation, they were on top of pain relief. Of course, I also had a doctor who was a firm believer in pain relief upon request in labor as well so maybe not representative of the whole.
I had a nurse look down her nose at me when I rang the buzzer for my pain medication (post c-section) that was more than an hour late and say “it is written as needed”. The director of the OB ward and I had a conversation about this after I went home and she said my hospital experience (including the above) was a “failure of basic nursing”.
For my first csection I was given all the pain medication I needed. For my second… they sometimes kept me waiting and I think they didn’t believe me when I said I was in pain. When I had my tonsils removed last year, they gave me all the pain killers I needed and even a sleeping pill so I could actually sleep at night. The hospital where I had my tonsils out did not have a maternity ward, and I feel they took my pain much more seriously.
I don’t know if its specific to maternity health care, or to women’s health care in general. I’m not sure that women in pain for whatever reason are taken seriously sometimes. I had major abdominal surgery a couple of years ago, and when I was back on the ward a few hours after recovering from the anaesthetic, the nurse came round asking if I needed pain relief. Yes please, said I. Her response was ‘I’ll come back in an hour and see how you’re doing then.’
Women and the elderly… it’s like they apply the same myth to us as fish or lobsters – we’re so “other” that we must feel no pain. My grandmother died in agonizing pain after suffering a fall and basically breaking the entire left side of her body (shoulder, forearm, hip). At the point where it was clear her organs were shutting down and she was not going to survive, a nurse actually said “we don’t want to give her too much because she might get addicted”?! Are you fucking kidding me? I was furious. We actually considered buying street drugs because she was in so much pain and they wouldn’t give her enough pain relief, but we were afraid we would cause more harm than good, and we didn’t really know how to use them. I think there are spoons involved and a lighter, but I really have no idea.
That’s so awful to read, your poor grandmother. I think it must be a default position for some health care personnel to assume the worst about patient motives-i know that there are patients who are seeking pain meds and go round EDs and family doctors trying to get prescriptions, but failing to provide sufficient analgesia is unethical and cruel. I think it’s maybe a generational thing too-my aunt, when asked directly about pain downplayed it, she didn’t want to complain. It was always ‘I’ll cope, there’s others worse off than me’. She is a tough old bird, but when she told me she couldn’t turn over in bed because it hurt too much I knew it must be agony for her, and it was only after me really pushing that she owned up to how bad it was. She physically couldn’t get herself off the sofa, she stayed there all night until early morning when she phoned a neighbour to help her up. And the GP was ‘what do you expect at your age?’ Hopeless, patronising, dangerous, fuckwit-I dread to think what’s happening to his other patients. She has refused to complain about her treatment (not that she actually got any from him), and I worry that other patients could be having a poor standard of care. I saw the private rheumatologists letter to him though-it was a literary masterpiece. Very polite, but basically ‘what kind of brainless moron are you?’ so maybe that might trigger a bit of introspection.
This is a very timely post for me. I developed a minor prolapse immediately after my second child was born by vaginal delivery several years ago- a relatively large baby and it was a tough delivery. Well, I recently had my third baby, even larger and delivered vaginally after I argued and begged for a c-section throughout my entire pregnancy and was denied due to it not being “medically indicated”. And guess what? Just as I feared, all the significant progress I’ve made with pelvic floor exercises has been ruined, my bladder is again falling down, but even worse, I now seem to have developed an enterocele when I never had any issues there before. It is so so unfair that women can be denied an elective c-section- yes, it’s surgery, but the data shows it’s a very reasonable option, especially for a woman who isn’t likely to have many more pregnancies. My ob/gyn claims that a c- section wouldn’t have helped prevent this, that the damage was already done from the previous birth, and that pelvic floor physiotherapy will take care of everything. Maybe she’s right, maybe not, but I should have been able to make the very reasonable choice to have an elective c-section.
That was very unreasonable of them. So much for the NCB people claiming that women are being pressured into having C-sections!
I had to have surgery for prolapsed organs and endometriosis when I was 29. Three vaginal deliveries, one of them an emergency forceps delivery, not to mention undiagnosed EDS, will do that to a person.
not to mention you obs do all the hard work for the delivery itself. Boy, that thought was in my head when kid 2 was half way through.